Pelvic organ prolapse (POP)

Published by suzanneyates on Dec 11, 2018

Pelvic Organ Prolapse (POP)

One of the things I love about teaching is seeing how my students take a topic which is dear to their heart and research it further and in their own way. I feel that Lara has gathered together some really useful information on pelvic organ prolapse which is relevant for us all. It contains things I knew less about! I hope you enjoy it and please share it.

Lara Montgomery completed the Pregnancy massage course recently and wrote her project , informed by her own experience of pelvic organ prolapse (POP). I feel it contains important information which adds to my blog on Pelvic Girdle Instability and am excited to be sharing her work with you. Lara lives and works in Bristol, like me, and you can find her details under Find a practitioner. If any of you suffer from pelvic organ prolapse (POP), you may want to consider having a massage with her.

I find massage and shiatsu are potentially valuable tools in supporting women with pelvic organ instability and pelvic organ prolapse (POP) as long as the therapist understands the role of the pelvic floor muscles. More and more in my teaching and work, I am integrating including pelvic floor exercises during the sessions. I find that when women (and men!) are in the quiet relaxing space of a massage or shiatsu session, they can focus their attention more internally: which is important when exercising the pelvic floor. I find this important as many people don’t know how to correctly do their pelvic floor exercises, as Lara discusses. Most of the yoga classes I go to don’t focus on the pelvic floor: even though it is a vital part of yoga: the mula bandah. I also find many teachers don’t correctly explain the breathing and the importance of engaging but also relaxing the muscles. Pelvic floor and abdominal abdominal muscles should be contracted using the out breath and relaxed using the in breath, as this is what happens physiologically when we breathe. This is a subject which merits more attention and Lara discusses this. However, it is also important, as Lara says, to adopt a full body approach and not simply focus on one area like the pelvic floor. A good bodywork therapist should be assessing the whole pelvis as well as its connections to the rest of the body. I find the meridian approach of Chinese medicine is very useful as well in terms of not isolating one area but linking it to the whole body. Girdle Vessel is particularly important.

It is important to have an internal examination to fully assess pelvic organ prolapse (POP): so clients need to include work with a therapist who does internal work eg a women’s health physiotherapist or certain osteopaths. In Bristol we have Helen Hodder who works both privately and in the NHS as a women’s health physiotherapist, who has also trained with Tami Lynn Kent (author of Wild Feminine). It may be possible to get a good physiotherapist on the National Health Service (in the UK), but it depends, as ever, on where you live and again Lara describes her experience with different physiotherapists.

I would like also to thank Burrell Education for letting us use their diagrams. Jenny Burrell has a fitness training background and works with integrated movement and Thomas Myers myofascial approach. For her pelvic floor exercises she includes awareness of the front line (adductors) which links a lot with Conception Vessel and Penetrating Vessel in Shiatsu, the back line (anterior ligament along the spine) with links with Governing Vessel and the lateral line (obturator and piriformis) which links with the side aspect of Girdle Vessel.

Above all, the key message of Lara’s project is “listen to yourself and your body” and work with what feels right for you.

A study for Wellmother Pregnancy Massage: Pelvic Organ Prolapse (POP)

by Lara Montgomery

“I have wanted to write something on the subject of Pelvic Organ Prolapse for some time. My aim is to consolidate and share all the information I have read, seen and experienced over the years, in hope that this knowledge can be of some help to other women.

It has been three years now since the birth of my third child, and three years of living with a pelvic organ prolapse. I had heard of a prolapse, I thought I knew what it was, I even joked around with friends about my weak pelvic floor and how I one day would probably have one!

In reality, I realise now, that I knew nothing about it, nothing at all. In fact, I have quickly realised that not many people understand what it is. Scarily, I am not sure how many women know what POP is, which is horrifying considering that the statistics show that over 50% of women will experience some form of POP at some point in their lifetime. From my research and personal experience in the field, I think it is more like around 65% plus of all women, because it is such an unspoken subject. And that is why I wanted to write something, to start the conversation on Pelvic Organ Prolapse.

If we think that over half of the female population experience some degree of prolapse…That’s BIG! And we sit here today with such a lack of information available and more importantly a serious lack of knowledge amongst us, including the doctors, physios and care workers. It is altogether shocking!

Why are we not talking about it? Do women realise that a tiny bit of leaking urine on a trampoline shouldn’t just be the norm for all women of a certain age? Are we embarrassed? Whether it’s talking to young girls, pregnant women, or women approaching the menopause…why don’t we talk about the health of our reproductive organs? Why don’t we talk more about our vaginas? It is unspoken/ taboo, it is considered embarrassing, it is kept quiet and for women who experience POP, they do suffer in silence, rarely even making it to the GP to discuss what might be done to help and support women. But then, is there really the help out there?

My story of pelvic organ prolapse

I remember the day very well. My son was one week old. I had rested well in bed all week. My motto has always been one week in bed and one week on the sofa! But after the first week, I wanted to get up and go out with my family. My two older girls were desperate for me to be up and about and so we went to the park. It was nice, relaxed and local, with my husband around to help with everything. I could feel that something wasn’t quite right. I had an uncomfortable pain in my pelvis, along the transverse muscles going down into my groin. I ignored it and carried on regardless. That evening I haemorrhaged, and with it something else came out. I didn’t really understand what it was. The wall of the inside of my vagina, I guessed, or perhaps my uterus? I wasn’t quite sure, but I was very scared. So, we went straight to hospital. When we were seen, I was told it was no big deal, I asked the doctor if it was a prolapse and he said yes, but probably only a ‘first degree’, and it would be fine, but to mention it to my GP at my 6-week check. I was given no advice, nothing, even though whatever it was, it was still present outside of my vagina opening.

I rested for another week with my feet up as much as possible, as much as you can with a new baby and two other small kids! At my 6-week check, my GP was lovely and did the normal checks, but I had to ask if she could examine me internally, to see if I did have a prolapse, which seemed to be out of the norm. She said she could see no prolapse present, as I was lying there, and sent me away. I knew something wasn’t right and so I booked an appointment to see a well-known gynaecologist privately. She confirmed what I already knew. I have a grade one/two cystocele (prolapse of the bladder) and uterine prolapse. She was very knowledgeable and measured me, doing an internal in different positions, including standing. She reassured me that it was very early days and postnatally things would improve dramatically. She suggested working with a physio, using a pessary, letting my body heal for 6 months to a year and then seeing where we were then and discussing my options. She referred me to a women’s health Physio. The Physio was supportive, but she also scared the life out of me. I was told not to walk anywhere, not to hold and rock my baby at all, to always have him in the pushchair even around the house and do to Kegel exercises all day as much as possible. I went away terrified. So, scared to move in the wrong way, or to stand for too long. I went back to the GP to tell her that I did in fact have a prolapse and that I wanted to see an NHS Physiotherapist. Every day, I would take the kids to school in the car and then go home and sit on the sofa all day, because I wanted to feed and cuddle my baby as much as possible, I didn’t want to put him down, as I had always used a sling in the past and putting him in a pushchair when he was so little felt uncomfortable to me.

I spent hours, days and months researching pelvic organ prolapse and quickly discovered that there, wasn’t much out there and you really had to look hard. There was a massive difference of opinions on pelvic floor, postural alignment and whether to ‘Kegel or not to Kegel?! I finally got through to see a women’s health Physio on the NHS. She was so unbelievably different from the private Physio. After the internal examination, she said I had now overworked my pelvic floor so much, I need to stop immediately and her advice was to go away and relax for the whole month, no Kegel’s at all, but deep belly breathing to learn to let go of the pelvic floor…. I was completely shocked and even more terrified! She reassured me that all would be ok, that my insides wouldn’t actually fall out, which was honestly what my biggest fear was. It may sound silly and completely obvious, but I was so scared of everything falling out! I did as she suggested and this was the beginning of my journey, getting to know my body, listening and feeling.

I did get an appointment with the NHS gynaecologist, who recommended a hysterectomy asap. I was 6 months postnatal. Needless to say, that I didn’t take his advice.

I realised then, that nobody really knew about POP, whether to do surgery or not, whether to Kegel or not? So, I went away, still feeling scared, but on the positive side, with an opportunity to really get to know my body, how it worked and what would help the symptoms. What I needed to do to move forwards and be the active mum I wanted and needed to be for my children.

It became acutely apparent to me, that every professional was trying to treat the symptoms, but nowhere was there a person willing to see the whole picture, the whole woman.

I embarked on a journey of self-discovery. I found a Pilates teacher who had had a prolapse herself, so I went twice a week to see her. An osteopath who helped re-align my pelvis, an acupuncturist who worked energetically. I changed my nutrition. I worked with a women’s health herbalist, taking herbs and tinctures, drinking certain teas and bathing in medicinal herbs every day, I even used herbs internally, vaginally. I found a massage therapist that worked with women postnatally. She did pregnancy massage and Arvigo abdominal massage, which made such sense to me. On her advice, I went away and followed my instructions to massage my tummy every evening.

Slowly but surely things started to change. I regained strength and confidence, I knew my body well and even though I knew the prolapse was still there, I couldn’t feel it. I had learnt to measure where my cervix was at different points of my menstrual cycle. I was symptom free and most of the time I couldn’t feel it anymore, with the exception of perhaps a couple of days before my period started. I learnt how to use the pessary myself, just for those days around my period for support.

But now, I don’t use anything. I do notice when I haven’t been active or haven’t been stretching and strengthening as much as possible, or haven’t been keeping up with my massage. But, then I get back on track and listen to what my body needs. It’s all about self-care, and through self-care I have learnt to be the mother than I wanted to be.

What I haven’t mentioned yet in any detail, is how this all made me feel. This is a crucial part of pelvic organ prolapse which is underestimated and not discussed. In those first few weeks, I opened up to other mothers about my prolapse. I realised incredibly quickly that it wasn’t to be spoken about, it seemed to make people feel uncomfortable, perhaps? Honestly, I think people actually knew nothing about POP, apart from a few myths, for example:

it only happens when you were overweight and/or unfit

you should had done your Kegels

you’ll never have sex again

it was an older women’s problem

it means you must wee constantly all the time

All of which are not true! But there are so many misconceptions about what a prolapse is.

And more importantly it is considered embarrassing and so you shouldn’t talk about it publicly. This I found shocking, and I felt even more alone and unsupported. I realise that it was never mentioned it in our NCT classes, the midwives never talked about it and even when I did, they didn’t really know much at all. Why aren’t we simply educated? Why is the health system not better informed and why is it a silent problem that so many women suffer with alone?

I was horrified to read about the prevalence of uterine prolapse in Nepal, and how in their culture women are considered redundant after a prolapse and often experience emotional and physical abuse from their family and or community because of the stigmatisation surrounding the condition. This is so culturally different from where we are in UK, but there is an essence there that I am curious about, the importance of women and care and how this is viewed within our society.

I think there are many emotions that women with POP go through. Feeling confident within your own body and your own sexuality is something that changes anyway as we get older, and with whatever life experiences we have, liked having children. One comment said; 80% of women said that after having developed the condition they lost hope in life.

Even if it is just a little leaking while jumping on the trampoline, which left untreated could cause so many problems later in life, women should have the knowledge to enquire if everything is OK, rather than thinking it is just part of life. Plus, surely we could save the NHS so much time and money in the long run?

Here, I wanted to talk about prolapse and firstly, just to outline and educate what POP is.

Gathered knowledge of Pelvic organ prolapse

What is Pelvic Organ Prolapse?

Pelvic Organ Prolapse (POP) is when one or more of the organs within a women’s pelvis drop from their natural position and bulges into and sometimes out of the vagina. It can be the uterus, bowel, bladder or the top of the vagina.

All the pelvic organs are supported by a very complex hammock of muscles, ligaments, fascia and fibres that attach to the bony anatomy of the pelvis. When these are weakened, damaged or under pressure, those organs can drop, unsupported.

Normal pelvic anatomy

There are different types of prolapse and it is common to have more than one type of prolapse at the same time. The main types are;

Cystocele – Anterior wall prolapse, when the bladder bulges into the front wall of the vagina.

Rectocele – Posterior wall prolapse, when the rectum/bowel bulges into the back wall of the vagina

Uterine prolapse – when the uterus/womb descends into the vagina, with varying grades of descent.

Enterocele – small intestine prolapse

Vault prolapse – when the top of the vagina descends, this happens to some women after the uterus has been removed.

POP will usually be measured on a scale of 1 to 4 to show how severe it is, 1 being mild and 4 being a severe prolapse. Or referred to as mild, to moderate, to severe.

What are the symptoms?

Each woman’s prolapse will depend on the type and the severity of the prolapse. You may not have any symptoms at all and may only discover you have a prolapse during a routine smear test.

The most common sign is the feeling of heaviness in the vagina, an increase of pressure, pain, backache and dragging, in the vagina and rectum or both. Especially if you have been on your feet all day, which is often helped and relieved by lying down.

Some women describe the feeling of a lump or like your insides are falling out, or like sitting on a ball.

Sometimes you may be able to see a lump or protrusion into the vagina.

Urinary and faecal incontinence.

Constipation or incomplete bowel emptying, you may need to push back or support the prolapse to allow stools to pass.

You may feel the need to urinate more often and or a sensation that your bladder is not emptying properly.

Leaking urine while jogging, jumping, coughing and sneezing can sometimes be a sign of a mild prolapse.

Painful intercourse and lack of sexual sensation.

An inability to keep a tampon in place.

A prolapse is diagnosed by performing an internal vaginal examination. The examination should be performed lying down and whilst standing up to get a full understanding of the type and grade of prolapse.

How common is Pelvic Organ Prolapse POP?

Pelvic organ prolapse is an extremely common condition that has been on medical records for over 4000 years.

It is difficult to know just how many women are affected by POP. Many women are simply not aware and others are reluctant to go and talk to their doctors about it.

It is estimated that globally around 50% of women suffer from at least one form of POP in their lifetime. But researchers fear it could be much higher. Statistics for the prevalence of POP in most countries are sorely lacking, true figures are difficult to estimate as there is little screening in place and many women feel too embarrassed to mention the symptoms and to get help.

Research indicates that in 2010, there were 3.3 million women in the US alone with POP. There are said to be 600,000 plus women in Nepal with uterine prolapse. A study by WHO (World health organisation) indicated that half of all women in their study in Lebanon had some form of POP and ‘guestimates’ currently indicates that there are 34 million worldwide with POP. And lastly 20% of women in the UK waiting for major gynaecological surgery are women with pelvic organ prolapse.

What causes POP (Pelvic Organ Prolapse) to happen?

POP is believed to happen when the group of muscles, ligaments, tissue and fascia that normally support the organs, becomes weakened and cannot hold everything in place.

There are many different ideas on how these components become weakened. But essentially there has not been enough research to enable us to really understand how body movement and connections between how everything works, as far as I can understand.

The risk factors for developing POP are;

Family history of POP

Vaginal childbirth, complications with large birth weight, long second stage of labour, assisted labour – forceps, episiotomy, perineal tears. The impact of childbirth may not necessarily show immediately, but as many as 20 years later.

Being overweight or obese

Menopause:hormonal oestrogen levels drop, which impacts the strength, elasticity and density of muscle and connective tissue.

It is important to mention that it is also possible for women who have never been pregnant or given birth to have POP.

What can we do to help POP?

Firstly, it is always important to see a health professional and get a diagnosis. If it is confirmed that a woman has some type of prolapse, there are many different options depending on how mild or severe.

Mild or grade 1-2 and with either symptoms or no symptoms present, there is a chance that it can improve with lifestyle changes.

Management and lifestyle changes are key to POP as well as working with an experienced women’s health physio

Options for Management of POP

Lifestyle

Nutrition, opting for as a natural diet as possible will help any anti-inflammatory situation within the digestive system and help with bowel movements. Losing weight if you are overweight will help. Avoiding constipation. Remember that your pelvic floor and diaphragm are working together to support your pelvic organs, but also your digestive organs, so it does make a difference if everything is working well and not inflamed. There are many different healing foods that can help restore the balance with in the body and things like Bone broths, which are full of collagen, a protein that helps to rebuild and strengthen muscle and connective tissue, for example.

Avoiding high impact physical activity, such as trampolining and possibly running on hard surfaces.

Stopping smoking – it can cause coughing, making the prolapse worse.

Pelvic floor strengthening

Some health care professionals recommend Kegels to prevent or heal prolapse problems. However, some may say that once you have POP, to be aware that Kegels can sometimes cause a downward movement pressure which could make things worse. Ideally, you need to find an experienced women’s health professional to work with, so if you do Kegel exercises, you want to be doing them correctly. Whatever you choose is best for you, always remember to prepare your breath and work the muscles on the out-breath only, and always remembering to fully relax the pelvic muscles each time. You do not want short tight muscles; you want muscles that have a full range from relaxation to strength.

Core stability exercises and movement, such as Pilates, yoga and considering primal movement/nutritious movement, Hab – it, Mutu System and Restore Your Core, to name a few, links are shown below.

Posture – Poor posture can put undue stress on your pelvic muscles. It is hugely linked into movement and exercise and learning to stand, sit and move in a way that naturally engages the core and pelvic muscles effectively. Wearing high heel shoes automatically puts your body into misalignment, so be aware and learn about your posture. Wearing supportive and comfortable flat shoes will help.

Walking – Walking is actually great exercise for POP and strengthening your pelvic floor. Perhaps thinking about walking more in the morning, rather than in the afternoon, when your pelvic floor muscles may be more tired.

Swimming is a lovely gentle way to exercise with POP and often recommended. Be aware to vary your strokes, as even though you feel supported in the water, you don’t want to thrust your ribs outwards too much, therefore discounting the effective use of the pelvic floor with the diaphragm.

Breathing – Intra-abdominal breathing is a huge part of fitness and pelvic floor strength. There are a few different approaches and ideas about what is best, so it’s important to read through and try to see which theory and breathing exercises you prefer. When we talk about the hammock of pelvic floor muscles, they are not alone, they are connected to our diaphragm, to our spine and all work as a whole, so breathing is a big part of the healing process with pelvic organ prolapse and diastasis recti.

Abdomen

Complementary Natural therapies are becoming more and more popular as people begin to realise and the see the positive effects.

Osteopathy and chiropractors – having the pelvis re aligned and in its optimal position greatly helps the function of the connecting muscles and fascia.

Massage – Abdominal massage called Arvigo massage, said to help realign the reproductive organs. Full body and Abdominal massage has been used for many years in different cultures throughout life, but especially during a women’s journey through pregnancy and childbirth and beyond. In some cultures, in places like India and Belize, women are given daily massage after giving birth, helping to strengthen the tummy and guiding the internal organ back into place. As well as increasing the blood flow and lymph to the abdominal area, helping to heal the muscles and connective tissues. There are also certain essential oils, herbal oils and ayurvedic oils that can help to strengthen muscle and tissue that can be used during a daily massage.

Acupuncture and Shiatsu – Traditional eastern methods can help to support and strengthen a woman with POP, believing that working on the spleen and liver points can gives strength and power to hold up the organs. (Suzanne: “I would add in that the Girdle Vessel is the horizontal meridian which regulates the pelvis and links together Liver and Spleen as well as Kidney and Yin and Yang and is a powerful integrated way of linking together different energies and muscles groups as well as addressing the emotional aspects) There is a well-known point named Bai hui which translates as 100 meetings because it has had the tradition of being able to treat 100 diseases. This point is right on top of the head and is an important point when treating prolapse, drawing the energy upwards.

Herbal medicine – There are many traditional herbal plants that help support and heal muscles and connective tissue, but also rebalancing hormones. Red raspberry leaf, horsetail, lady’s mantle, comfrey, horse chestnut to name but a few. It is important to find a herbalist specialising in women’s health, who will have the knowledge and experience.

Pessary

A pessary is a good way of supporting a prolapse. Mainly made of latex or silicone (although some natural sponge) pessaries are devises that provide structural support when placed into the vagina. They come in all shapes and sizes, so it is advisable that you see a health care professional to go through the options. Fitting the correct size of pessary is important and may take more than a couple of attempts. They can be used to ease symptoms of moderate to severe prolapses. Some will need to be fitted professionally and can stay fitted for up to 3 months, then being removed and cleaned, checked and reinserted. Other types, you can put in and remove when you like. Vaginal pessaries allow you to get pregnant in the future and they can be a good alternative to surgery. It is unlikely to cause any problems, but may on occasion cause inflammation.

Surgery

If non-surgical options have not worked or if the prolapse is too severe, surgery may be an option.

There are several different types of surgical procedures for POP, which your doctor or gynaecologist will go through with you.

It is worth mentioning that if you wish to have children or more children, your doctor may suggest waiting until after your family is complete, as pregnancy and birth may cause the prolapse to reoccur.

Generally, you will need 12 weeks’ rest and to be off work after a prolapse surgery.

While surgery for POP is an option, it must be noted that there is a 30% recurrence rate for women choosing this route. Prolapse repairs can be done transvaginally, abdominally, laparoscopically and/or robotically. Ultimately the purpose is to correct the anatomy as well as provide a better bowel, bladder and vaginal function.

A pelvic floor repair surgery is usually performed through the vagina, tightening up to support the pelvic organs. In recent years, a number of new operations have been developed using a new mesh as the supporting material and is sewn into the vaginal walls. There has been a lot of controversy regarding this mesh migrating within the body, causing devastating, lifelong problems for many women across the world. NICE (National Institute for Health and Care Excellence) have banned it from being used inside the vagina now, but it is still sometimes used on the outside of the vagina to support the uterus, through an abdominal surgery. It is worth reading up on this subject as much as possible and discussing with your gynaecologist before your surgery. Sacrocolpopexy or sacrospinous fixation is a type of surgery that aims to lift and attach your uterus or vagina to the back of your sacrum. This would normally be done through keyhole surgery.

Colpocleisis is surgery that closes off your vagina altogether. This type of surgery is performed if you are in very poor health or if you have had several POP surgeries previously that have now been unsuccessful.

NB: No operation can promise to cure your prolapse, but many offer a good chance of improving your symptoms. There are risks with every operation. 30% of women having POP surgery will develop another prolapse in the future. Although I believe this is higher than research suggests and once you go down the surgery path, it can be years of more and more surgery.

What can we do to prevent pelvic organ prolapse?

One of the most positive directions we can take is to increase awareness so women around the world can start to recognise the symptoms of pelvic organ prolapse when they first appear.

Essentially this part is all about education and communication

Women need to talk; health care professionals need to be educated. We need more research and understanding into the female anatomy.

In France and possibly other countries, a postnatal woman is always given a 6-week course of Physiotherapy, where her pelvic floor function is tested and an appropriate course of treatment offered. It would be amazing to have this level of care after childbirth.

Slowly there are more and more people speaking up about prolapse and a much-needed focus on pelvic floor rehabilitation that is more dynamic and not simply getting people to do Kegels repeatedly.

There are people around the world that are learning and running interesting research projects into POP and links with child birth and levetor ani/pelvic floor muscles avulsion (tears) and tissue damage. They talk about the links and about how to really evaluate women with POP, not just with an internal exam, but scans and other imagery. And teaching physios to be able to palpate and feel unseen internal tears that affect the function of the pelvic floors muscles.

Eventually, I am hoping that the more research like this, the more education and knowledge will follow.

Summary of Pelvic Organ Prolapse POP

POP is a condition which effects a high percentage of women and can be scary, heart breaking and debilitating, not to mention very uncomfortable.

There is little common knowledge or education to give women the understanding they need to make informed decisions and to help themselves.

This is my journey and I have shared my opinions on pelvic organ prolapse and what has helped and supported me. But I urge you, more than anything, to learn to listen to your body and your instinct and try to feel what is right you. For me, this journey was, and is, about calling me into my body; a positive experience that I cannot express enough here while writing how valuable that has been for me!

The benefits of massage during a women’s childbearing years is so valuable and often overlooked or considered a luxury. Working with women during fertility, pregnancy, birth, postnatally and the menopause, all with massage, is an area that I feel especially passionate about.

There is a reason why in many cultures women massage other women during these important transitional times. I think it’s important for society, an area that I am curious about, and something that I would like to study more in the interest of bringing further knowledge and understanding to more women.